Improvements & Sustained Change through the Implementation of High Reliability Units

Tammy Van Dyk, MSN, RN, CPEN Quality Management & Patient Safety Manager

Objective

• Describe how high reliability principles adopted at the unit level can positively impact process reliability and patient outcomes

East Tennessee Children’s Hospital

• Comprehensive Regional Pediatric Center

• 152 Licensed Beds

• 35 ED Beds

• Annual ED Volume 70,000

Knoxville, TN

Background

• 1999-To Err is Human (IOM)

• Failure to Recognize & Delayed Reaction

• Lacked a Total Systems Approach

• Barriers to Unit Level/Staff Engagement

• Failure to Sustain Change & Outcomes

Ideal State

• Have we fixed our problems?

• What are the recommendations?

• What do other industries do?

Literature Review

• Weick & Sutcliffe – 5 Principles of Mindful Structure

• Preoccupation with Failure

• Sensitivity to Operations

• Reluctance to Simplify

• Commitment to Resilience

• Deference to Expertise

• Helen Devos Children’s Hospital – Kamishibai Rounding

Align with Strategic Initiatives

Solution: Creation of HRU

• Goal

– Creates & maintains safe culture @ unit level

• Benefits

– Reduce retrospective chart audits

– Real-time coaching

– Improved collaboration

– Heightened awareness, transparency, ownership

– Increased accountability

– Alignment with hospital goals

HRU: Key Steps

• Leadership Support

• Education

– Error Prevention Training; Safety Coaches; High Reliability; Cause Analysis; Leadership Methods

• Identify key stakeholders to drive the change

• Implement Kamishibai Rounding

• Commit to Resilience

– Bounce back, shared learning, celebrate successes

Kamishibai Rounding

Available in CLABSI, CAUTI, VAP, Pressure Injuries, & Falls Coming Soon: Medication Safety, Readmission Discharge Bundle, Unplanned Extubation, VTE, PIVIE

Preoccupation with Failure: Real-Time Observation & Coaching

Sensitivity to Operations: Transparency & Learning

Deference to Expertise Driving Change & Accountability

Success

• HAC reduction and improved process reliability

• SPS Hospital of the Month in December 2015

• SPS top performing hospital: CAUTI, CLABSI, VAP

• Increased near miss reporting (Preoccupation with failure)

• Family Participation in HAC prevention

• Press Ganey Pinnacle of Excellence Award 2015

• Reduced Cost

HAC reduction

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45

2014 2015

Nu

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ETCH Hospital Acquired Conditions

46% reduction; 22 fewer patients harmed

Includes CLABSI, CAUTI, VAP, VTE, ADE, Fall w/injury; SSI; PU in all inpatient care areas

Improved Process Reliability

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Catheter Associated Urinary Tract Infection (CAUTI) Maintenance Bundle Reliability

% Hospital reliability to bundle

Centerline

June 2015 HRU launch with Kamishibai bundle rounding

Achieved 640 Days CAUTI free!

Improved Process Reliability

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Central Line Associated Blood Stream Infection (CLABSI) Maintenance Bundle

% Hospital reliability to bundle

Centerline

2014: Reporting was mostly chart review and sporadic

June 2015: Kamishibai card rounding & HRU implementation improved capture with real data capture of bundle compliance

Improved Process Reliability

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Pressure Injury Prevention Maintenance Bundle Reliability

% Hospital reliability tobundle

Centerline2014: Collection of Reliability was inconsistent and relied on retrospective chart review

June 2015: Kamishibai card rounding & HRU implementation improved capture with real data capture of bundle compliance

Unit Level Performance: PICU HRU

Sustained Improvement- PICU: 5 years VAP free

HRU

Add Daily CHG bath

HRU

Unit Level Performance: PICU HRU

HRU

HRU

Reduction in harm with HAPI past 3Q after HRU/Kamishibai rounding

Staff driven initiatives to improve medication delivery

Increased Near Miss Reporting

181

208

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250

Med Event Near Miss Reporting

FY15 Near Miss Reporting FY16 Near Miss Reporting

15% increase in Near Miss Reporting from FY15 to

FY16

Financial Impact

$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

2014 2015

Estimated Costs of ETCH Hospital Acquired Conditions

Cost Savings of over $460,000

*Excludes Readmissions

HAC Cost References

DESTINATION ZERO

"The names of the patients whose lives we save can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers

are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have

known, and holidays will be taken, and work completed, and books read, and symphonies heard, and gardens tended that, without our

work, would never have been."

Donald M. Berwick, MD, MPP Former President and CEO

Institute for Healthcare Improvement

Expansion of HRU

Error Prevention Training

Safety Coaches

Leadership Methods & High Reliability Principles

PICU Pilot HRU

2nd HRU: Inpatient Surgery

3rd HRU: NICU

4th & 5th HRU: Inpatient Med-Surg & Heme/Onc

Expansion: OR, ED, Clinics

2017 Spring 2014

Oct 2014

Winter 2015

June 2015

Nov 2015

Apr 2016

June 2016

Resources

• ₁ Institute of Medicine (IOM). 2000. Committee on Quality of Health care in America; Kohn, LT, Corrigan, JM, Donaldson, MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press [Report issued in 1999, published in 2000}

• ₂ Jurecko, L. (2015). Lean tools help prevent hospital acquired infections. Children’s Hospital Today, July 20. Retrieved from https://www.childrenshospitals.org/Newsroom/Childrens-Hospitals-Today/Summer-2015/Articles/Lean-Tools-Help-Prevent-Hospital-Acquired-Infections

• ₃ National Patient Safety Foundation (NPSF). (2015). Free from harm: Accelerating Patient Safety Improvement Fifteen Years after “To Err is Human”. Boston: NPSF.

• ₄ Weick, K, & Sutcliffe, K. (2007). Managing the unexpected: Resilient performance in an age of uncertainty. San Francisco, CA: Jossey Bass.